Interventional Rads: Vascular vs. Abdominal vs. Oncologic

[asaha]

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Hi,

I'll be starting radiology residency in 2010. I love the procedural experience of interventional radiology, and want to learn more about the different sub-sub-specialties of this field.

Vascular seems exciting, but some of the downsides I see are long hours and turf wars with cardiologists/vascular/CT surgeons. Since they have first dibs on patients, I'm concerned that IR will get a dwindling slice of the pie in the future.

I've seen a few programs that offer abdominal interventional fellowships. I'm thinking they do stuff like biopsies and drainage of gallbladers and abscesses. I would think the lifestyle is much better than vascular. True?

Finally, I've increasingly been hearing about interventional oncology: thermo/radiofrequency ablations, chemoembolizations, etc. Does this fall under the realm of abdominal interventional, vascular interventional, or is it completely separate fellowship training? I would also think that interventional oncology has a much better lifestyle than vascular since there are few emergencies.

If anyone could shed light on the distinctions in training, lifestyle, and compensation between these fields within interventional radiology, I would greatly appreciate it. Thanks in advance!

 

[hans19]

Hi,

I'll be starting radiology residency in 2010. I love the procedural experience of interventional radiology, and want to learn more about the different sub-sub-specialties of this field.

Vascular seems exciting, but some of the downsides I see are long hours and turf wars with cardiologists/vascular/CT surgeons. Since they have first dibs on patients, I'm concerned that IR will get a dwindling slice of the pie in the future.

I've seen a few programs that offer abdominal interventional fellowships. I'm thinking they do stuff like biopsies and drainage of gallbladers and abscesses. I would think the lifestyle is much better than vascular. True?

Finally, I've increasingly been hearing about interventional oncology: thermo/radiofrequency ablations, chemoembolizations, etc. Does this fall under the realm of abdominal interventional, vascular interventional, or is it completely separate fellowship training? I would also think that interventional oncology has a much better lifestyle than vascular since there are few emergencies.

If anyone could shed light on the distinctions in training, lifestyle, and compensation between these fields within interventional radiology, I would greatly appreciate it. Thanks in advance!

I think you have a big misconception about IR. The sub sub sub sub specialization you characterize doesn't exist. You are trained, in theory, to do any or all of what you've listed. What you do depends on your practice environment. Outside of Sloan Kettering or MD Anderson, you won't do pure interventional oncology. In fact even at MSK or MDA i doubt you do exclusively ablations or chemo/radio embolizations. I'm sure those guys do biopsies drain abcesses, place lines, drain kidneys just like any other IRs.

No matter where you are, patients will get abcesses, and you will be asked to drain abcesses. No matter where you are people will get lung nodules and liver masses and you will be asked to biopsy those masses. If it comes back malignant, and the patient is not a candidate for definitive surgery, you will be asked to ablate, embolize said tumor. Patients will need kidneys drained, fistulas declotted. The lines are blurred.

As far as pure vascular, that never existed. In its heyday endovascular inteventions were primarily done by IRs. And IRs were draining abcesses and doing biopsies then as well. So pure vascular to the exclusion doesn't exist, unless you pursue vascular surgery. More and more there is competition from VS and cardiology, so on the whole IRs are doing much less peripheral vascular work.

 

[irwarrior]

Interesting post. SIR is really pushing service lines. ie 1. peripheral vascular disease 2. oncology 3. pain interventional 4. women's therapies (fibroids)

These can all be achieved in the right IR fellowship but it requires clinic with preop and longitudinal follow up.

For eg
in my monday clinic I saw in the am
1.a fibroid consult
2.follow up s/p fibroid embo
3.2 thoracic aneurysms
4. aaa (now 5.5 , been following for a couple years at 4 cm)
5. Renal stent consult times 2
6. Chemoembo consult for metastatic sarcoma
7. multiple bilateral renal masses (consult for ablation)
8. TACE follow up

We have a group of 5 interventionalists and so we subspecialize to some degree. my focus is on vascular and oncology. The key is building referrals and a busy clinic. But, it takes time to grow it. Lots of talks. Strong comfort with the disease and knowledge of disease. The 3 of us who have alot of clinic are busy doing the outpatient cases and the 2 others who don't like clinic do most of the inpatient procedures piccs, paras, thoras, abscess drains etc.

Ultimately if the IR primary certificate happens (5 year IR residency). Then most likely there will be fellowships including vascular and oncology.

 

[gonogo]

Very interesting post! I'm also starting residency in 2010 and have considered going into IR or neuro IR. I'll be in a very academic program and will have a good amount of protected research time. I was wondering if it'd be advisable to do my research in IR as opposed to something else (?). Also, are IR and neuro IR very different? Obviously one has to do with the brain and the other one doesn't, but I mean in terms of the techniques used and the skills needed.

 

[drjaymehta]

dont you think a lot of Interventional work, though once upon a time owned by the radiologists is now being lost out to..
though VIR is excellent for research, but have heard of the nephro guy doing renal stents and the cardio guys going around stenting everything they can and obviously the neuro doing his own stents..

 

[irwarrior]

Well, I personally think competition is healthy. If we did not have competition then the field would not be as robust as it is today. It has made the SIR finally realize if we as a society do not learn the disease and take care of patients like every other specialty, it will not last. The new younger IR are much more clinically aggressive and because of this are building (vein practices, fibroid practices, pain practices (vertebroplasty/kyphoplasty), aneurysm practices (I don't need a cutdown with the perclose proglide you can do the entire procedure percutaneous), peripheral vascular disease (knowledge of the disease and data will allow you to give talks to primary care and patient groups).

The IR guys innovate and then would traditionally hand it of to other specialties. But, with the clinical practice, you talk to the patient directly and the patient could care less if you are IR, vascular surgery, cardiology, nephrology etc. They just want you to listen and take care of them. Now, in order to practice in this model you certainly need to hone your clinical skills which unfortunately most interventional radiologists lack. You need to be able to administer plavix, aspirin, pletal, statins, zyban, ace inhibitors etc for your vascular patients. You need to know the importance of CHAD score in afib and whom to put on coumadin and why. You need to know the data cold. So, the key is clinic and the busier the better with that will come procedures, hospital admissions, and so on so forth. It entails a bit of work but will allow you to have an exciting and rewarding practice.

4 things will determine who does what.

1. clinical control of patients (most important)
2. Number of practitioners
3. Research
4. Technical ability (perhaps least important)

There has never been a more exciting time in the history of IR as we continue to become more of a true clinical specialty. More like surgery and cardiology than diagnostic radiology. The primary certificate of interventional radiology will allow motivated medical students who want to just do IR and not imaging to pursue that path.